Sex and the metacities

Mumbai and Dhaka's populations continue to grow, their slums full to bursting. What are the different ways in which their inhabitants are trying to take control over their own fertility and sexual health?

Apartment life for ex-slum dwellers brings more space, but less sense of community. Photograph: Guy Walder

They're making up new words for cities like Mumbai and Dhaka. Megacities are becoming metacities. Cities so big they stretch the very definition. Cities that heave with people, where families live wherever they can, jammed in slums against railway tracks or the airport runway.

"We are expected to become the secondbiggest city in the world," says Dr Jairaj Phatak, the municipal commissioner of Mumbai, a small man behind an endless desk. He tries to look proud. The mayor, sitting across town in her colonial bungalow, smiles brightly: "Mumbai will be havoc!"

Dhaka has seen its population double in the past 15 years, Mumbai in the past 25. Both are chasing the magic 20 million mark, when they become "meta", and both have swelling slums cramming the inner city, and extending around the periphery. Over half Mumbai's population lives in slums. In some parts they say there are 50,000 people living to one square kilometre. People living this close get sick, and pregnant.

Mehrunisa and Zosna, two women in their 30s living a country apart, are both expecting babies. It's Zosna's second, and Mehrunisa's fifth. Zosna, who lives in a Dhaka slum, is apprehensive about giving birth. Mehrunisa just wishes the whole thing wasn't happening. She lives in Shivaji Nagar, a slum on the outskirts of Mumbai, 12 miles and a world away from the cool marble of the mayor's residence. It's built on the city's biggest dump and crawls with flies and goats. The huts seem to grow out of the filth and trash, flapping with loose plastic and Vodafone adverts torn from walls to make roofs. Scraps of tarpaulin wave like flags in the wind. She is sanguine about her new child: "I have no choice now."

Choice is a rare commodity here. Shivaji Nagar is a socially conservative, predominantly Muslim slum, where husbands and mothers-in-law rule and an unwritten code says that women should be having children. Contraception and abortion are viewed with profound suspicion.

Nasimbee, a neighbour of Mehrunisa, lets rip. "Why should I have another child?" She's already had five and now does her family planning on the sly. It's not hard, she says, since her husband "lost his brain" to drink and drugs: "He won't find out, he can't find out." These women are conducting a covert operation, fighting their husbands, their culture, the system. And once they've battled with the family, problems await. Mehrunisa has stomach pains and wants to get an ultrasound, but can't afford it. Even if she could, the machine in the municipal hospital has been broken for years. Anita Shenoy, a tired-eyed doctor at the single public clinic that serves the 600,000-strong slum admits they struggle to meet demand: "There is a big queue here in the morning ... people can't wait." Instead they go to private clinics but these, she adds, are often bogus — fake doctors with made-up qualifications trying to make a quick buck by selling sham drugs.

A thousand miles north, the Dhaka slum rises out of water, not rubbish. Shacks are built on bamboo stilts, and black streams froth with pollution beneath. The local ward commissioner Anhaj Mahmud has a mantra for what's happening on his patch: "Population and corruption, corruption and population." His brother Mohammed, a wealthy property developer, is more specific: "Me? I have one son, one daughter. Look over there, they have six ..." But Zosna and her neighbours have a different take: "We all know that two children is a happy family." After two, they have an injection or go on the pill. Their mothers, they say, had five or six children. Not them. These women are lucky though — they live within reach of a Marie Stopes clinic that doles out contraception and advice.

Everyone agrees with the ward commissioner on one thing. Corruption is everywhere, from the party leaders banged up on corruption charges, to the forestry department official who was busted with wodges of cash stuffed in his pillowcases. Department for International Development health adviser Fran McConville describes the country as a "paradox". Bangladesh has made extraordinary social progress, especially in health. But this is thanks to what she describes as a "phenomenally strong NGO community": in other words, despite the government, not because of it. It's a picture the director general of family planning seems happy to endorse. She says the government has a "lack of manpower" in the slums and that it's up to the NGOs.

Government action?

Masudus Salehin, a Marie Stopes programme manager working in the Dhaka slums, feels the weight of this responsibility, and questions whether the government shouldn't carry more of it. "We're not able to reach all the houses ... there are lots of gaps." He knows there are still women who have no idea how much easier they can make their lives by choosing how many children they have, and when. In Mumbai, Dr Shenoy echoes his frustration. If there could be another public clinic, if services could be made more available, it would be different.

But in the Victorian corridors of the Municipal Corporation of Mumbai, the agenda seems to be elsewhere. Dr Phatak raises his voice: "The slum dwellers aren't as poor as you think. They can easily earn 100 rupees [a little over a pound] a day." He claims they have "the easiest interface with the municipal health structure" and that the corporation's focus is not on primary healthcare and local clinics where women like Mehrunisa could get vital family planning advice, but on rural services and the hospitals in central Mumbai.

His solution for the slums is to wish them away. It's a policy of repulsion. "We don't give them facilities. We make it difficult for them to live here. But we can't remove them and throw them away because our country today allows people from anywhere to go anywhere so it is very difficult to uproot these people." He looks almost wistful.

Mehrunisa does not want to be uprooted. This is home, dump and all. And the slums will never magically vanish; Mumbai is a magnet to people all over India. They're going to keep coming, and they're going to keep having children. Dr Phatak hopes that Mumbai's "prosperity" will match its population. It might. But the women in the slums won't see much of it. For that to happen the corporation must first recognise them, then accept that this city is their home, and then provide them with the services they so desperately need.